Infectious Disease ECHO (USET)

This case form is for the Infectious Disease ECHO hosted by United South and Eastern Tribes, Inc.

To submit a case, fill out the form below.

If you have any questions about this case form, please contact bhendrix@usetinc.org.

Your Name:
Please enter a number less than or equal to 125.
Sex at Birth:
Insurance:

Liver Related History

Cirrhosis?
Any evidence of clinical decompensation?
Previous HCV Treatment?
Heptocellular Carcinoma?

Other History

Medical Diagnoses:
If other relevant diagnosis, please list here:
Psychiatric Diagnosis:
If other, specify:
Depression Screening (if available):
If other, specify:

Substance Use History

Does this person have a substance use history?
History of injecting drugs?

Current Medications

Medications:
Medication Name
Dosage
Frequency
 
Click the plus symbol to add multiple medications
If oral contraceptive, does it contain ethinyl estradiol?

Body Mass Index (BMI)

Hepatitis Vaccination and Labs

Hepatitis A total or IgG antibody:
Hepatitis B surface antibody (anti-HBs):
Hepatitis B core antibody (anti-HBc):
Hepatitis B surface antigen (HBsAg):

Labs

(if available)
(genotype)
(for patients with known or suspected cirrhosis)

Fibrosis Score

(for cirrhotic patients only)
(for cirrhotic patients only)

Imaging

(e.g. ultrasound, fibroscan, etc.)

Other

Please send me a copy of my responses:

By submitting this form, you have acknowledged that Project ECHO case consultations do not create or otherwise establish a provider-patient relationship between an ECHO clinician and any patient whose case is being presented in a teleECHO session. Always use Patient ID# when presenting a patient in clinic. Sharing patient name, initials or other identifying information violates HIPAA privacy laws.